Information Collection

NHBS Behavioral Assessment Survey (HET)

IC 196958 under ICR 202603-0920-004 · OMB 0920-0770.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0770 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-26-0109 Behavioral Assessment HET_English NHBS Behavioral Assessment Survey (HET)	Form
Form 0920-26-0109 Behavioral Assessment HET_Spanish NHBS Behavioral Assessment Survey (HET)	Form
0920-26-0109 Behavioral Assessment HET_English Att 3d_Behavioral Assessment HET_Eng.docx	Form
0920-26-0109 Behavioral Assessment HET_Spanish Att 4d_Behavioral Assessment HET_Span.docx	Form

IC Title:

NHBS Behavioral Assessment Survey (HET)

Agency IC Tracking Number:

0920-26-0109

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-26-0109				Yes	Yes	Fillable Fileable
Form	0920-26-0109				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,500	167	3,333
Annual IC Time Burden (Hours)	875	-848	1,723
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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